| Label | Type | Description | Mandatory |
| Updated On | CURAM_DATETIME | The date on which the last update was made to the evidence. | No |
| Effective Date of Change | CURAM_DATE | Date which the evidence becomes effective | No |
| Approval Requested | CURAM_INDICATOR | Approval Requested | No |
| Amount | CURAM_AMOUNT | Medical expense amount incurred by the household member. | No |
| Frequency | EVD_MEDICAL_EXPENSE_FREQ | Frequency indicating how often the amount is paid from the drop-down list of frequencies, e.g., "bi-weekly" or "monthly". Your system administrator can add a new frequency via the Code Tables page (see "Code Tables" in the Cúram Administration Guide). | No |
| Last Payment Date | CURAM_DATE | Date on which the last medical expense payment is made. | No |
| Medical Expense Type | EVD_MEDICAL_EXPENSE_TYPE | Medical expense type that is incurred by the household member from the drop-down list of medical expenses, e.g, "dental care", "prescription drugs", or "cost of prescribed equipment". Your system administrator can add a new medical expense type via the Code Tables page (see "Code Tables" in the Cúram Administration Guide). | No |
| Start Date | CURAM_DATE | The Date on which the medical expense begins. | No |
| End Date | CURAM_DATE | The Date on which the medical expense ends. | No |
| Written Off Amount | CURAM_AMOUNT | Amount that the medical provider has written off for a member who is elderly or disabled. | No |
| Reimbursement Type | EVD_EXPENSE_REIMBURSEMENT_TYPE | Reimbursement type for medical expenses that are reimbursed from the drop-down list of reimbursement types, e.g., "federal assistance program", "insurance company", "state assistance program". Your system administrator can add a new reimbursement type via the Code Tables page (see "Code Tables" in the Cúram Administration Guide). | No |
| Reimbursed Amount | CURAM_AMOUNT | Amount reimbursed to the household member for the medical expense. The system subtracts this amount from the medical expense amount to determine the actual medical expense value. | No |
|
| Updated By |
| Label | Type | Description | Mandatory |
| Updated By | USER_NAME | | No |
|
|
|
| Medical Expense Details |
| Label | Type | Description | Mandatory |
| Household Member | FULL_NAME | Household member to whom the medical expense evidence applies from the drop-down list of household members. Note that the system displays the primary alternative ID of each of the members displayed on the drop-down list. In the US, the primary alternative ID is the social security number (SSN). | No |
|
| Medical Service Provider Details |
| Label | Type | Description | Mandatory |
| Medical Service Provider Participant | FULL_NAME | If the medical provider is a case participant, you can select the provider from the drop-down list of case participants. The system automatically creates an additional case participant role of "medical service supplier". | No |
|
| Comments |
| Label | Type | Description | Mandatory |
| Comments | COMMENTS | | No |
|
